Microneurosurgical management of distal middle cerebral artery aneurysms

Dashti, Reza; Hernesniemi, Juha; Niemelä, Mika; Rinne, Jaakko; Lehecka, Martin; Shen, Hu; Lehto, Hanna; Albayrak, Baki S.; Ronkainen, Antti; Koivisto, Timo; Jääskeläinen, Juha E.

doi:10.1016/j.surneu.2007.03.023

« Previous Next »Surgical Neurology
Volume 67, Issue 6 , Pages 553-563, June 2007

Microneurosurgical management of distal middle cerebral artery aneurysms

Reza Dashti, MD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Juha Hernesniemi, MD, PhD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
- Corresponding author. Tel.: +358 50 4270220; fax: +358 9 47187560.
Mika Niemelä, MD, PhD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Jaakko Rinne, MD, PhD
- Department of Neurosurgery, Kuopio University Hospital, Kuopio 70211, Finland
Martin Lehecka, MD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Hu Shen, MD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Hanna Lehto, MD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Baki S. Albayrak, MD
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki 00260, Finland
Antti Ronkainen, MD, PhD
- Department of Neurosurgery, Kuopio University Hospital, Kuopio 70211, Finland
Timo Koivisto, MD, PhD
- Department of Neurosurgery, Kuopio University Hospital, Kuopio 70211, Finland
Juha E. Jääskeläinen, MD, PhD
- Department of Neurosurgery, Kuopio University Hospital, Kuopio 70211, Finland

Received 5 February 2007; accepted 8 March 2007.

Abstract

Background

Distal middle cerebral artery aneurysms originate from branches of MCA distal to its main bifurcation or the peripheral branches. Distal middle cerebral artery aneurysms are the least frequently seen among the middle cerebral artery aneurysms. The purpose of this article is to review the practical anatomy, preoperative planning, and avoidance of complications in the microsurgical dissection and clipping of MdistAs.

Methods

This review, and the whole series on intracranial aneurysms, are mainly based on the personal microneurosurgical experience of the senior author (JH) in 2 Finnish centers (Helsinki and Kuopio), which serve without patient selection the catchment area in Southern and Eastern Finland.

Results

These 2 centers have treated more than 10000 aneurysm patients since 1951. In the Kuopio Cerebral Aneurysm Database of 3005 patients with 4253 aneurysms, 69 patients carrying altogether 78 MdistAs formed 5% of all MCA aneurysms. Among the 18 patients with ruptured MdistAs (23%), an ICH occurred in 9 (50%).

Conclusions

Distal middle cerebral artery aneurysms are rare. The microneurosurgical treatment of MdistAs is challenging. They are often difficult to localize during the operation, and lack of collateral circulation makes their occlusion more demanding. High rate of ICH and high tendency of rebleeding urge acute or emergency surgery in most of ruptured cases. Microneurosurgical clipping is the most effective treatment of MdistAs.

Abbreviations: CTA, computed tomography angiography, DSA, digital subtraction angiography, ICA, internal carotid artery, ICG, indocyanine green, ICH, intracerebral hematoma, LSO, lateral supraorbital approach, MbifA, middle cerebral artery bifurcation aneurysm, MCA, middle cerebral artery, MdistA, distal middle cerebral artery aneurysm, M1A, middle cerebral artery trunk (M1) aneurysm, SAH, subarachnoid hemorrhage, STA-MCA, superior temporal artery to middle cerebral artery anastomosis